A Wholly-Owned Subsidiary of Centene Corporation
Inpatient Request Form
Fax to: 1-844-818-9289
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TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved. Version 4.0 11/1/2017 HF0917x118 (10/17)
Admission
Type
!!Emergency!Admit*!
!!!!!!Date!of!Admit:!!
!!!!!
!
!!Elective!Admit!!
!!!!!!Anticipated!Date!of!Admit:!!
!!!!!
!
*For%emergency%admissions,%if%face%sheet%is%attached ,%please%put%sponsor’s%Social%Security%number%here:%______<____<______!
Facility
Type
!Acute!Care!Hospital!
!Acute!Rehab!!!
!!!!!!Facility/Unit!!
!Long!Term!Acute!Care!(LTAC)!
!Skilled!Nursing!!
!!!!!Facility!(SNF)!
Psychiatric!Inpatient!Admissions!
!Acute!Psychiatric!Emergency!
Admission!
!Elective!Admission!to!a!
Residential!Treatment!Center!
(for!children!and!adolescents)!
!Elective!Psychiatric!Admission!
for!Eating!Disorder!
Substance!Use!Disorder!
Inpatient!Admiss io n s!
!Detox!(not!medical!
admission)!
!Substance!Use!Disorder!
Rehab!
!
Partial!Hospitalization!Program!(PHP)!
!Psychiatric!(to!include!eating!!
!!!!!!!disorder!PHP)!
!!!!! !Full!Day!!! !Part!Day!
!Substance!use!disorder!rehab!
!Full!Day!!! !Part!Day!
!
Intensive!Outpa tie n t!P r og r a m !(IOP)!!
!!!!!! !Psychiatric!(to!include!Eating!!!!
!!!!!Disorder)!
!Substance!Use!Disorder!
Services!for!Active!Duty!
Service!Members!ONLY!
!Inpatient!PTSD!A ct ive !
Duty!Program!
!
Patient Information
SPONSOR!SSN/DoD!Benefits!Number:!!
!!!!!
!!
Patient!Date!of!Birth:!!
!!!!!
!
Patient!Last!Name:!!
!!!!!
!!!
First!Name:!
!!!!!
!!!
Middle!Initial:!!
!!!!!
!
Address:!!
!!!!!
!
City:!!
!!!!!
!
State:!!
!!!!!
!
ZIP:!!
!!!!!
!
Home!Phone:!!
!!!!!
!
Other!Health!Insurance!!! !!Yes!! !!No!!!
Policy!#:!!
!!!!!
!
Carrier:!!
!!!!!
!
Requesting Provider Information
Is!the!requesting!pro v id er!p e rfo r m in g!t h e!s er vic e? !
!!Yes!
!!No!
Provider!Name:!!
!!!!!
!
Contact!Name:!!
!!!!!
!
Phone:!!
!!!!!
!
Fax:!!
!!!!!
!
NPI!#:!
!!!!!
!
Tax!ID!#:!!
!!!!!
!
Servicing Provider Information
Provider!Name:!!
!!!!!
!
Specialty:!!
!!!!!
!
Phone:!!
!!!!!
!
Fax:!!
!!!!!
!
Address:!!
!!!!!
!
City:!!
!!!!!
!
State:!!
!!!!!
!
ZIP:!!
!!!!!
!
Hospital/Health Care Facility Name (Required)
Name:!!!
Phone:!!
!!!!!
!
Fax:!!
!!!!!
!
Address:!!
!!!!!
!
City:!!
!!!!!
!
State:!!
!!!!!
!
ZIP:!!
!!!!!
!
Requested Service: If additional codes are being requested, please attach additional sheets or use additional comments field below.
Diagnosis!Code:!!
!!!!!
!!!
Description:!!
!!!!!
!
Diagnosis!Code:!!
!!!!!
!!!
Description:!!
!!!!!
!
Diagnosis!Code:!!
!!!!!
!!!
Description:!!
!!!!!
!
CPT!Code:!!
!!!!!
!
Description:!!
!!!!!
!
Units!(BH):!!
!!!!!
!!
Frequency!(BH):!!
!!!!!
/week!
CPT!Code:!!
!!!!!
!
Description:!!
!!!!!
!
Units!(BH):!!
!!!!!
!!
Frequency!(BH):!!
!!!!!
/week!
CPT!Code:!!
!!!!!
!
Description:!!
!!!!!
!
Units!(BH):!!
!!!!!
!!
Frequency!(BH):!!
!!!!!
/week!
Please!submit!clinical!information!necessary!to!process!this!request.!Additional!comments:!!
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